REV I EW ARTICL E KERALA MEDICAL JOURNAL

Vertigo-An Overview
PG Dhanyaa, VG Pradeep Kumarb
a. Government District Hospital, Kozhikode; b. Baby Memorial Hospital, Kozhikode*

ABSTRACT Published on 26th March 2009

Human beings maintain equilibrium utilizing a sophisticated system. Vertigo is a very disquieting sympyom. Analysis of the symp-
tomatology and clinical picture is needed to ascertain the cause of vertigo in any given case.
Keywords: Vertigo, Types and evaluation

*See End Note for complete author details

Man has developed a very sophisticated system by which It may not be always possible for the patient to differ-
perfect equilibrium is maintained. Sensory information entiate between the two symptoms and they may often
from the eyes and vestibular apparatus together with complain only of a feeling of instability.
proprioceptive information from the neck and limbs
passes to the central nervous system where, at the level Physiology Vestibular System
of the vestibular nuclei, it is integrated and modulated Vestibular labyrinth is composed of two parts:
by activity arising in the cerebellum, extra pyramidal
system and cortex. Pathways arising from the nuclei 1. Semicircular Canals that respond to angular accelera-
connect with five main systems; the cerebral cortex, tion.
occulomotor nuclei, the motor part of spinal cord, the 2. The Otolith Apparatus that respond to linear
cerebellum and the autonomic nervous system resulting acceleration.
in static and dynamic spatial orientation and control
of locomotion and posture. Pathology affecting the The two halves of the vestibular system should be
central nervous system, cardiovascular system, the eyes, maintained in perfect balance for equilibrium.
the ears, the locomotor system, blood and endocrine
During head movements vestibular input alters along
gland may all alter this balance of neural information
with visual signals and cervical and proprioceptive
and result in disequilibrium.
input. From birth, this information is stored in the
Dizziness I VERTIGO reticular formation of the brain stem (data centre).
Afferent information is always compared with this
Dizziness is a term that comprises a number of data bank and normally there is a perfect match and
symptoms of disequilibrium including light headedness, equilibrium is maintained. If the function of any of
faintness, giddiness, sensations of floating, imbalance these is impaired and mismatch occur between the
ataxia, mental confusion or loss of consciousness. In information generated by one sensory modality and
other words it is a feeling of “as if about to fall”. that of the other, symptoms of disequilibrium arise.
Vertigo is a specific
Table 1. Causes of Dizziness/Vertigo
symptom related directly
General Medical Otologial Neurological Miscellaneous
to dysfunction of the
a. Haematological: l. Trauma, 1.Disorders of Vlllth Nerve l. Cervical vertigo
vestibular system. By anaemia, polycythaemia 2.Infection 2.Brainstem disease 2. Ocular vertigo
definition, vertigo is a b.Cardiovascular: 3.Vascular 3.Cerebellar disease 3. Laterogenic
“hallucination of move c. hypotension, cardiac failure, 4. Menieres disease 4.Cerebrovascular disease
dysarrhythmia 5. Auto immune disorders 5.Multiple sclerosis
ment (Cawthrone 1952) or d.Metabolic: 6. Ototoxicity 6.Trauma
“disagreeable sensation Diabetes mellitus, 7. Metabolic bone disease 7.Infection
of instability or disorder hypoglycemia, 8. Structural abnormalities 8.Epilepsy
chronic renal failure, alcohol of the vestibular labyrinthine
of orientation in space.

Corresponding Author:
Dr. V G Pradeep Kumar, Consultant Neurologist, Baby Memorial Hospital, Kozhikode.
Phone: 9447034443. Email: vgpradeep@hotmail.com
10 Kerala Medical Journal | January-March 2009 | Vol II Issue 1
PG Dhanya and VG Pradeep Kumar. Vertigo-An Overview

DIZZINESS
Recurrent episode

Cochlear Symptoms No cochlear Symptoms

1. Menieres disease No associated Symptoms Associated symptoms

2. Infection BPPV Neurological
3. CP angle lesion Cervical vertigo
General medical causes

Single episode Continual imbalance

Cochlear sympts No cochlear Symptoms

1.Vascular labyrinthine lesion No associated symptoms Associated symptoms

2.Labyrinthinefistula 1. Inner ear lesion 1. Vascular brainstem lesion
3. Viral labyrinthitis 2. Vertibular Neuronitis

Cochlear symptoms No cochlear symptoms

1. Brainstem lesions 1. Postural hypotension
2. CP angle lesion 2. Cerebellar disease
3. Oto- toxic drugs 3. Multiple Sclerosis
4. VB
Figure 1. Diagnositc approach to Dizziness / Vertigo

Diagnosis: is based on epilepsy and vertebrobasillar ischaemia)

1. A proper history
2. Full medical examination with reference to the ears,
eyes, neurological assessment
3. Specific special investigations.
By considering the character of complaint, duration of
illness and presence or absence of associated symp-
toms-cochlear, neurological or cardiovascular we often
get a clue to the diagnosis.
Some Generalizations:
1. Vertigo is commonly associated with a vestibular
disorder
2. Dizziness is commonly related to general medical
disorder
3. Sudden, unexpected, short lived episodes
ofvertigo- peripheral vestibular disorders
4. Gradual, insidious onset of continual imbalance -
central disorder (exception include temporal lobe
5. Duration
BPPV- duration of individual attacks 30-40
seconds Menieres disease lasts upto 24 hours.
Labyrinthine failure vertigo lasts for many days
6. Associated symptoms: Audiology symptoms like
hearing loss, tinnitus, sensation of fullness in
the ear and painful lesions of labyrinth or VIIIth
Nerve.
Benign Paroxysmal Positional Vertigo ( BPPV)
Most common clinical syndrome following minor
head injury. Symptoms develops after a symptom free
interval of days or weeks. It can also be seen after viral
infections of upper respiratory tract.
Symptoms
Brief severe episode of rotatory vertigo lasting less
than a minute upon sudden changes of head position
especially on lying down and turning towards the
affected ear.

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PG Dhanya and VG Pradeep Kumar. Vertigo-An Overview

Findings: Table 2. Characteristics of Peripheral Vs Central Vertigo

Symptoms or sign Peripheral Central
Dix Hall pike Maneuvers
1. Latency (time of onset No latency, begins
• Latent period 2-20 sec followed by vertigo/ 0-40 seconds
of vertigo/nystagmus) immediately
nystagmus with or without nausea nystagmus - Symptoms may
2. Duration 1 minute Yes
linear rotatory with fast phase towards affected persist
ear lasts <1 minute. 3. Fatigability (lessening
of signs and symptoms
• Absence of symptoms and signs on repeated Yes No
with I repetition of pro-
testing (fatigability) vocative manouvre)
Fixed, torsional,
Pathophysiology: 4. Nystagmus direction
up, upper pole Direction changes
of eyes towards variable
Thought to arise due to pathology in the posterior semi ground
circular canal Severe vetigo Usually mild vertigo,
5. Intensity of signs and
marked nystag- less intense nystag-
1. Theory of “Cupulolithiasis” proposed byS- Symptoms
mus, nausea mus, rare nausea
chuknecht in 1969. 6. Reproducibility Inconsistent More consistent
2. Theory of “Canalolithiasis’ proposed by Brandt
and Stedden in 1993. exclusion, Neuhauser et al have suggested diagnostic
criteria
According to this theory, Otoconia!debris forms a free-
floating clot in the posterior semicircular canal. Rapid Definitive criteria
changes of head position with respect to gravity 1. Episode of vestibular symptoms of at least
causes the clot to move and induce endolymph flow moderate severity vertigo, positional dizziness and
and cupular deflection head motion intolerance
Pharmacotherapy 2. Migraine according to International Headache
Society Criteria
1. Role not clearly established
3. One or more of the following features during at
2. Best avoided where possible to allow central
least two vertigo attacks
nervous system compensatory mechanism
Migrainous headache
3. Drugs employed symptomatically are
Headache
• Phenothiazines
Photophobia
• Ca++ channel antagonists
Phonophobia
• Antihistamines
Migrainous aura
4. Betahistine (histamine receptor agonist) has a pro-
phylactic role and is widely used. 4. Other diagnoses excluded by appropriate test

Liberatory Manoeuvre - Canalith Repositioning Probable:

Procedure
• Proposed by Epley
• To use head position and vibration to cause free
canaliths to migrate out of PSCC to the inert region
of the utricle.
This maneuver has produced successful results in most
patients and if the symptoms recurs, the maneuver can
be repeated.
Migrainous Vertigo
Migrainous vertigo, although not recognized in the In-
ternational Headache Society Schema, is a commonly
diagnosed entity among neuro-otologists. The
diagnosis requires clinical suspicion and is one of
Criterion 1 and 4 as above plus s at least ONE of the
following
• migrainous headache
• migraine symptoms during vertigo
• migraine specific triggers of vertigo response of
anti migraine drugs.
Migrainous vertigo is a diagnosis of exclusion and
because some patients may have symptoms and
signs (including nystagmus) suggestive of central
dysfunction, neuroimaging may be required at first
presentation. AI though there have been no adequate
randomized trials of treatment of migrainous vertigo
in the clinic setting, most neurologist use standard anti-

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PG Dhanya and VG Pradeep Kumar. Vertigo-An Overview
migraine prophylactic drugs (propanalol, amitryptilline
etc) with reasonable success.
INVESTIGATIONS
The laboratory investigation, like the physical
examination, should be directed particularly by the
patients history. If there is a history of presyncope or
syncope, the patient must have a cardiac evaluation, and
an electrocardiogram. All patients with undiagnosed
vertigo should have metabolic screening tests, including
blood cell count, electrolytes, blood glucose, ESR
and thyroid function test. The presence of auditory
symptoms requires audiometric tests. Multiple or
recurrent cranial neuropathy requires screening test
for collagen vascular disease or basal skull lesions
or meningitic process. Vertigo with cerebellar signs
definitely requires CT scan or MRI of brain.
END NOTE
Author Information
1. Dr. PG Dhanya, Consultant, ENT Surgeon,
Government District Hospital, Kozhikode
Kerala Medical Journal | January-March 2009 | Vol II Issue 1
2. Dr. V G Pradeep Kumar,
Consultant Neurologist, Baby Memorial
Hospital, Kozhikode
Conflict of Interest: None declared
Cite this article as: PG Dhanya, VG Pradeep Kumar.
Vertigo-An Overview. Kerala Medical Journal. 2009
Mar 26;2(1):10-13
REFERENCES
1. Baloh RW. Approach to the evaluation of the dizzy patient. Otolar-
yngol Head Neck Surg. 1995 Jan;112(1):3–7.
2. Baloh R.W. Vertigo in Older People. Curr Treat Options Neurol.
2000 Jan;2(1):81–9.
3. Epley JM. The canalith repositioning procedure: for treatment
of benign paroxysmal positional vertigo. Otolaryngol Head Neck
Surg. 1992 Sep;107(3):399–404.
4. Neurology in clinical practice:Walth G Bradley et- al Volume: l,
page 231-241
5. A practical approach to acute vertigo Barry M Seemugal et al
Practical Neurology 2008; 8:211- 221
6. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert
T. The interrelations of migraine, vertigo, and migrainous vertigo.
Neurology. 2001 Feb 27;56(4):436–41.
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